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Old 12-17-2015, 08:35 PM
 
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If your doc's office says you owe X dollars but your EOB says that you are not responsible for that amount and after repeated phone calls to both offices, doc still says you owe and insurance still says you don't, what do you do next? Do you still have to pay it even though insurance says you don't have to?

How do you resolve this kind of problem?
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Old 12-17-2015, 10:37 PM
 
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Did the insurance pay anything for the service? This sounds like the old "non-covered services" predicament. A service is provided that is not covered by insurance, so the doctor bills the patient. Then the insurance company sends an EOB that says the doctor cannot charge the patient or they are in violation of their contract with the insurance company (assuming this is an IN-network doctor). If this is your situation, then it depends on state law. Some states have enacted "non-covered services" laws to keep insurance companies from pulling this scam which forces the doctor to buy your healthcare for you. The problem is that the insurance company will not tell the doctor in advance. The service is "pre-authorized" by the insurance company as a covered service. But after the service is performed and the claim is submitted, they say it was not a covered service in that particular situation.

Can you give us more information? Is the doctor in-network? I have had multiple instances where an insurance company I was out-of-network with treat me like I was in-network.
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Old 12-17-2015, 10:39 PM
 
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Quote:
Originally Posted by ChiGal7 View Post
If your doc's office says you owe X dollars but your EOB says that you are not responsible for that amount and after repeated phone calls to both offices, doc still says you owe and insurance still says you don't, what do you do next? Do you still have to pay it even though insurance says you don't have to?

How do you resolve this kind of problem?
Check the paperwork you signed at the Doctor's office when you approved your treatment it will more than likely have a paragraph there regarding the amount you "could" owe after the insurance has paid.
Also, the Explaination of benefits only tells you the amount the insurance covers, the insurance company cannot mandate the amount the Doctor charges.
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Old 12-17-2015, 10:44 PM
 
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Quote:
Originally Posted by CSD610 View Post
Check the paperwork you signed at the Doctor's office when you approved your treatment it will more than likely have a paragraph there regarding the amount you "could" owe after the insurance has paid.
Also, the Explaination of benefits only tells you the amount the insurance covers, the insurance company cannot mandate the amount the Doctor charges.
Unless the doctor is in-network.
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Old 12-17-2015, 10:52 PM
 
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Quote:
Originally Posted by toofache32 View Post
Unless the doctor is in-network.


Not true, an in network Doctor agrees to an amount to be paid by the insurance company however, the Doctor can charge what they want but knows they will only receive a set amount from the insurance company, the rest is the responsibility of the patient/patient's guardian.
Read every word of the documents you sign for treatment and financial responsibility before you sign them.
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Old 12-17-2015, 11:12 PM
 
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The doctor is in network.

This was a portion of an in office procedure which is a separate line item on the bill. I've had it done before and there was never an issue. The insurance keeps saying that because it was a part of a covered service that was already paid then they can't charge me any more.
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Old 12-17-2015, 11:15 PM
 
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Also they didn't give me any separate paperwork to sign for this procedure. I have always just paid my usual copay when I've had this done before.

I don't know if I'm explaining it right. There was a procedure done which was paid for and this charge under dispute is listed as a separate line item for some reason but it was all done at the same time as a part of the procedure to help diagnose the problem.
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Old 12-18-2015, 01:32 AM
 
Location: Georgia, USA
30,466 posts, read 32,875,249 times
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Quote:
Originally Posted by ChiGal7 View Post
Also they didn't give me any separate paperwork to sign for this procedure. I have always just paid my usual copay when I've had this done before.

I don't know if I'm explaining it right. There was a procedure done which was paid for and this charge under dispute is listed as a separate line item for some reason but it was all done at the same time as a part of the procedure to help diagnose the problem.
We're anonymous here. What was the procedure and what is being charged separately by the doctor that the insurance company wants to bundle with that procedure?
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Old 12-18-2015, 05:02 AM
 
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Was the service a covered service? With the EOB showing you don't owe, I'm guessing it was. I would call the insurance company, talk to the customer service people first, if you don't get anywhere, ask to talk to the provider credentialing people and let them know what is going on. Unless there is something we don't know, not a covered service or something, the dr is in breach of contract and the insurance company will want to know this.
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Old 12-18-2015, 07:58 AM
 
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Originally Posted by Qwerty View Post
...talk to the provider credentialing people and let them know what is going on. Unless there is something we don't know, not a covered service or something, the dr is in breach of contract and the insurance company will want to know this.
+1
An in-network provider is in violation of their agreement with the insurance company if the EOB says you do not owe. Each company uses a different term (provider contracting, provider credentialing, network credentialing, etc.) but that department can contact the provider and let them know the rules.

The medical procedure you are describing is an "incidental procedure". Payment for incidental procedures are included with (bundled into) the payment for the more complicated procedure. Each insurance company has their own incidental procedure edits.
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